Provider Demographics
NPI:1386067718
Name:GONZALEZ, IBETTE (535)
Entity type:Individual
Prefix:
First Name:IBETTE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:535
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 N AZUSA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1257
Mailing Address - Country:US
Mailing Address - Phone:626-858-9940
Mailing Address - Fax:
Practice Address - Street 1:1406 N AZUSA AVE STE C
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-1257
Practice Address - Country:US
Practice Address - Phone:626-858-9940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2343325126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant